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David Oliver: Will robotic automation solve social care?

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Like David Oliver I have been unable to find out how the data relating to time saving was arrived at.

For occupational therapy the Darzi report quotes 25%.

My son is an occupational therapist working with children with special needs. Having heard about his working week, I cannot imagine how automation might free up 25% of his time. Indeed, in the paper quoted in the IPPR review from the Martin group in Oxford, occupational therapy is 6th out of 702 in order of job roles likely to be replaced by automation (probability 0.0035). Statisticians come in at position 213 (probablility 0.22).

Oliver is right to question the fanfare of the bright new future coming from the IPPR. Let us pause for a moment and look at automation in our current social encounters. A coffee from an automated machine is less satisfying than a coffee poured by a friend, sitting at a table where more friends gather. A vending machine does not give the same comfort that a familiar canteen cook can give in laughter, rapport and social engagement. I wonder if a placebo is as effective when given by a vending machine rather than a person who is talking to you?

In our ambition to improve, innovate and forge technology to health and social care, there is a worry we may be missing the obvious.

‘Ara Darzi, surgeon and former health minister, has this year called for “full automation” of “repetitive tasks” in health and care services’

Proposed robotic intervention can save finances in Social care by replacing people with robotic automation ! ‘Repetitive tasks’ still require sensitivity and compassion and a person’s individual needs to be gauged carefully each time they are supported. People don’t require the same support every time they need assistance. Repetitive tasks are far more than just assisting a person with washing or dressing, it is the personal contact warmth and compassion that a person is afforded that is an essential part of social care. Robotic assistance won’t have the intuition to know when someone’s needs are changing. Emotional needs are not quantifiable. It would be disastrous for care to be delivered in a merely task oriented way. People are not a tick list of tasks merely to be completed. Care requires knowledge, experience and compassion to be blended to support people’s needs. Care is a partnership, reliant on trust and a developing professional relationship. Robotic assistance isn’t sentient.

David Oliver is concerned by the call made by Ara Darzi, surgeon and former health minister, for 'full automation' of 'repetitive tasks' in health and care services, expressing scepticism about its purported benefits and warning that ‘we should never forget that health and social care is a people business and that those people might prefer more, not less, human contact.’ In response, Toby Prescott and Julie Robillard argue that while robotic automation is not a ‘solution’ to social care, it can nonetheless contribute to improving lives.

We agree that robotics may be a useful avenue to explore in the provision of care. However, we wish to stress the human aspect of high quality care. We find many of the ways in which care work has been characterised in the debate to be of concern, and we question the ways in which the provision of care is often presented by robotics advocates as involving ‘repetitive tasks’ ripe for ‘automation’. In general, work targeted for automation is routinely described as ‘dull’, ‘low skilled’, and even ‘menial’.

Our team is carrying out a programme of ethnographic research that involves detailed observations of the bedside care ward staff (nurses and healthcare assistants) provide for people living with dementia (a key demographic for the consideration of robotic assistance) during a hospital admission (1, 2). We note that our findings are from hospital settings of the acute ward but nonetheless are of relevance to the consideration of care in general. We strongly believe that this care is highly skilled, and that routine everyday interactions including the provision of personal care, medication, mealtimes, observation rounds, and continence care, are in fact often very varied, involving nuanced, finely negotiated interactions between ward staff (nurses and healthcare assistants) and patients. There are also great differences between such interactions for the provision of different types of care. There may be some tasks which could be ‘automated’ but currently, it is unclear to us how essential care could be taken over by robotic automation. It may be argued that robotics may free staff for the ‘human side of care’, but this makes the implicit assumptions that this is something over and above the routine everyday care work that takes place within hospital ward. The humanity of care and the communication with individuals takes place within the myriad encounters between patient and carer.

Moreover, our research (and the wider field of research examining the organisation and delivery of care) demonstrates again and again, that the emphasis on ‘efficiency’ which so often derives from the wider institutional drivers of tightly timetabled delivery of care to patients at the bedside, can frequently be counterproductive, for example with speed and efficiency often producing anxiety and confusion in patients and stress and burnout in staff. Robotics and its potential must be examined in the context of these wider social and institutional drivers underlying the challenges and priorities of delivering high quality care to patients.

Considerable weight to the impetus to explore robotics in social care can arise from awareness of the numbers involved. There is a shortage of nurses and other caring staff, with difficulties in filling vacancies and retention, together with an increasing population in need of various forms of care. However, whilst this is not in dispute, focus on this as a ‘numbers’ problem can seduce us into an attitude of ‘nurses and carers in short supply’: ergo, ‘fill the gap with robots’. This may focus our vision away from examining the systemic reasons behind the mismatch between carers and need. Whilst we are anxious not to oversimplify, our research indicates that there are systemic barriers to the provision of good quality care to people living with dementia within hospital settings which may also feed into the stress and burnout that contributes to poor staff experiences. Focusing on exactly what is happening in the highly complex human interactions between staff and patient in their social context, is a key to understanding both how robotics might assist, or might not be useful, as well as contributing to a greater understanding of some of the reasons underlying the challenges of delivering high quality care and of supporting and retaining highly skilled care staff.

The need for careful design in the development of social care robotics has been noted. We believe that this must include consideration of the complexity of the delivery of care within the wider social and institutional contexts, because this can help to reveal the complexity of these very human interactions, and help to shed light on the broader factors contributing to the challenges of care provision that those working in robotics wish to help address. Above all we must consider the different factors that contribute to the quality of care. Quality of care encompasses not only safety and effectiveness, but importantly, it must be delivered with humanity. Focus on the very concept of ‘automating’ care may, if we are not careful, lead us astray.

I thank Prescott and Robillard for their comprehensive and eloquent response. There is very little they have said that I would want to disagree with and I don't pretend to have their content expertise in this field.

However, I still can't find the basis of the assertions and assumptions made by the Institute for Public Policy Research about the scale of savings in person-hours or costs in the two tables they presented.

As a non-expert but someone interested in how data are presented to influence public policy and the provenance and quality of the data, it would be good if someone could explain the workings behind the tables to me and to readers.

David Oliver asks and answers the wrong question. Robotic automation will not “solve social care”, but it can contribute to improving the lives of people with care needs.

In the report for the EPSRC Robotics and Autonomous Systems (RAS) Network (1) we considered the state of social care in the UK, where standards of care are falling dramatically, even compared to ten years ago, and as evidenced by charities such as Age UK (2). We then explained the potential of robotics and automation to address some of the challenges that arise in care where technology could make a difference. We gave details of state-of-the-art systems, noting that that these are mostly early stage, explained some of the technical and research challenges to be overcome, and proposed a research roadmap for the next two decades, by which time the UK’s over 65 population will have increased by a further five million. A key focus of that paper, and of other international efforts in this area, is on the need for an interaction between designers, carers, and people in need of care in developing new technologies for care. Adopting design and development models that are responsive to the needs, priorities and values of end-users, such as co-creation and participatory design, will serve to ensure that emerging robotic solutions are needed, accepted and beneficial to all (3).

While David Oliver is correct in stating that evidence of impact is limited to date, the RAS Network White Paper did not attempt to quantify the benefits that these technologies will bring precisely because the research to demonstrate such impacts lies ahead of us. Funding for social care robotics, in the UK and abroad, increasingly requires careful, thorough and embedded evaluations of the effectiveness and acceptance of these solutions in addition to analyses of their economic benefit and commercialization potential. Furthermore, guidelines and frameworks for robotics development, deployment and implementation increasingly incorporate key ethical considerations, to ensure that these solutions lead to maximum benefit and that potential harms, including those raised in this piece, are minimized (1, 3).

David Oliver notes the alarmingly high levels of social isolation among older people. What should be palpably clear is that loneliness among people in need of care is not due to robots, that do not exist yet, but to systematic and societal issues in how their needs are valued. As other forms of work become automated, we consider that the activity of providing human care to others can and should be increasingly valued and better rewarded. There is little evidence, as yet, that speaks to the concern that introducing robots in care could increase social isolation, and there is certainly no inevitability that the use of automation in care will reduce human contact. Nevertheless, in the RAS Network white paper we advocate, as a precautionary measure, that the right to human contact in social care should be protected by legislation to ensure against any such eventuality. Loneliness is a complex phenomena, for which the presence of other people is not a guaranteed solution (4). In our view, social robots could play a role here, for instance by providing forms of interaction that help to break cycles of low self-esteem, or by providing a ‘social bridge’ to friends and relatives.

Compared to the billions we spend on medical research, the UK has invested, at most, some tens of millions in exploring the potential of assistive robotic technologies for social care, at a time when it is estimated that around 1.2 older million people in the UK have an unmet social care need (2). There are few areas of modern life where people do not consider that the introduction of better and appropriate technologies could improve lives. However, in the area of social care, there are a significant number of voices advocating for the status quo, in terms of technology, even while the quality of care is falling rapidly. Faced with this challenge, the responsible course of action is to explore all possible courses of action to achieve the highest standards of evidence-based care.

(4) Cacioppo, J. T. and Patrick, W. (2008) Loneliness: Human Nature and the Need for Social Connection. New York: Norton.

Competing interests:
Tony J Prescott is the Director of Sheffield Robotics, a multidisciplinary institute research across two universities in Sheffield UK, he is also a director and shareholder in Consequential Robotics a UK SME developing assistive and companion robots.
Julie Robillard is an Assistant Professor in Neurology at the University of British Columbia. She has no competing interests.